AIDS Behav (2017) 21:1016–1024
DOI 10.1007/s10461-016-1585-5
ORIGINAL PAPER
Retention, Antiretroviral Therapy Use and Viral Suppression
by History of Injection Drug Use Among HIV-Infected Patients
in an Urban HIV Clinical Cohort
Catherine R. Lesko1 • Weiqun Tong1 • Richard D. Moore1,2 • Bryan Lau1,2
Published online: 17 October 2016
Ó Springer Science+Business Media New York 2016
Abstract Compared to HIV-infected persons who do not
inject drugs (non-IDU), persons who inject drugs (PWID)
experience disparities in linking to medical care, initiating
antiretroviral therapy (ART) and achieving viral suppres-
sion. There has been little attention to changes in these
disparities over time. We estimated the proportion of
PWID and non-IDU retained in care, on ART, and virally
suppressed each year from 2001–2012 in the Johns Hop-
kins HIV Clinical Cohort (JHHCC). We defined active
clinic patients as those who had C1 clinical visit, CD4 cell
count, or viral load between July 1 of the prior year, and
June 30 of the analysis year. Within a calendar year,
retention was defined as C2 clinical visits or HIV-related
laboratory measurements [90 days; ART use was defined
as C1 ART prescription active C30 days; and viral sup-
pression was defined as C1 HIV viral load \400 copies/
mL. While PWID were less likely to be retained in earlier
years, the gaps in retention closed around 2010. After
2003–2004, PWID and non-IDU retained in care had
similar probability of receiving a prescription for ART and
PWID and non-IDU on ART had similar probability of
viral suppression.
Electronic supplementary material The online version of this
article (doi:10.1007/s10461-016-1585-5) contains supplementary
material, which is available to authorized users.
& Catherine R. Lesko
clesko2@jhu.edu
1 [10–12]. Specifically, prior research has suggested that
Department of Epidemiology, Johns Hopkins Bloomberg
School of Public Health, 615 N Wolfe St., Baltimore,
MD 21205, USA
2
School of Medicine, Johns Hopkins University, Baltimore,
MD, USA
123
Keywords Antiretroviral therapy
HIV care continuum

Injection drug use
Viral load suppression
Introduction
Given the reduced morbidity, mortality and infectiousness
associated with viral suppression on antiretroviral therapy
(ART), achieving viral suppression is the ultimate goal for
HIV-infected individuals, HIV providers and public health
practitioners [1–3]. Achieving viral suppression requires
successful transition through several steps, including HIV-
diagnosis, entry into medical care, retention in care, and
prescription of ART. This framework for measuring pro-
gress towards viral suppression in a population has been
dubbed the HIV care continuum [4, 5]. There are multiple
versions of the care continuum but one simple depiction is
available in Fig. 1. Examining attrition from one stage to
the next may give clues about potential targets for popu-
lation interventions to improve HIV outcomes [6, 7].
Examining the distribution of an HIV-infected cohort
across the continuum stages over time is a means for
monitoring progress towards improved public health sys-
tems for people living with HIV [8, 9]. Within a single
clinic (or health system), the HIV care continuum frame-
work can be used as a metric by which the clinic (one
entity within the larger public health system) can monitor
changes in clinical practices over time.
Injection drug use (IDU) is associated with poorer HIV-
related outcomes and faster progression of HIV disease
persons who inject drugs (PWID) experience greater delays
in linking to HIV medical care, are less likely to be retained
in care, are less likely to be prescribed ART and are less
likely to be virally suppressed once on ART [6, 13–15].
AIDS Behav (2017) 21:1016–1024
Fig. 1 Schematic depiction of the HIV care continuum, where the proportion in each stage (boxes) over time is of interest and arrows represent
patient movement through the continuum; this analysis focuses on the three unshaded boxes on the right
However, few prior studies have considered the association
between IDU and progression through multiple stages of
the HIV care continuum in the same cohort [16]. Further-
more, as ART regimens have improved (perhaps alleviat-
ing some concerns about initiating a patient with prior IDU
on ART) and clinical care models have evolved, we are not
aware of any studies that have examined how progression
through the HIV care continuum has changed over time for
PWID versus non-IDU.
Herein, we present estimates of the proportion of PWID
and non-IDU retained, started on ART and virally sup-
pressed by calendar year (unshaded boxes in Fig. 1), after
enrollment into care in a large, urban HIV clinic. In sec-
ondary analyses, we examine different markers of retention
and their association with IDU and calendar time.
Methods
Study Population
The Johns Hopkins HIV Clinical Cohort (JHHCC) consists
of all HIV-infected persons age 18 years or older who
enroll in HIV care at Johns Hopkins outpatient HIV clinic
and consent to share their data (approximately 95 % of
persons who enroll into continuity care). For this study, we
included all HIV-infected persons who enrolled in the
JHHCC since the cohort inception in 1995 through June 30,
2012, who had at least one clinical visit in the outpatient
HIV clinic or elsewhere on the Johns Hopkins medical
campus (the Johns Hopkins Hospital and associated
ambulatory clinics) or at least one CD4 cell count or HIV
viral load measurement between July 1, 2000 and June 30,
2012. We did not employ any exclusion criteria.
Patient characteristics including sex, race, age, HIV
acquisition risk factors, prior AIDS diagnosis, and prior use
of any antiretroviral drugs were ascertained through con-
versations between patient and physician at enrollment.
Collection of these data were standard (collected on all
patients) but not standardized (asked in the exact same
manner of all patients), and like all self-report data are
subject to recall bias and social desirability bias. Patients
1017
who reported IDU as a probable source of their HIV
infection when they enrolled into care were classified as
PWID. Baseline laboratory values were defined as those
measured closest to the date of study enrollment, within a
window 6 months prior to and 1 month after enrollment.
Patients enrolling in the JHHCC may be new to HIV care
or may be transferring care from another HIV provider.
Patients were classified as having AIDS at baseline if the
date of their first AIDS diagnosis preceded their enrollment
date. Patients were classified as ART-naı̈ve if they had not
initiated ART prior to their enrollment date. Collection of
data on patients in the JHHCC, and this analysis of that
data, were approved by the Johns Hopkins Hospital insti-
tutional review board.
The cohort of HIV-infected patients on which each
calendar year-specific estimate of retention, ART use and
viral suppression was based, varied. Because the JHHCC is
a clinical cohort, patients may transfer to another clinic and
not notify the JHHCC; for these patients, failure to return
to the JHU clinic is not the same as failure to be retained in
HIV care. Therefore, to estimate the probability of reten-
tion in a given year, we need to restrict the study sample to
the subset of patients ever enrolled in the JHHCC with
some indication that they are still actively enrolled in care
at JHU. We defined patients as ‘‘active’’ in a calendar year
if they had at least one clinical visit (within the HIV clinic
or in any other setting within the Johns Hopkins Medical
system), CD4 cell count, or HIV viral load between July 1
of the prior year and June 30 of the present year. CD4 cell
count and HIV viral loads conducted anywhere within the
Johns Hopkins Medical system or at one of two large
commercial laboratories in Baltimore are captured by the
JHHCC and are utilized in this analysis.
Outcomes Measurement
The primary definition of retention we used was attendance
at C2 clinical visits or HIV-specific laboratory measure-
ments (CD4 cell count or HIV viral load) [90 days apart
between January 1 and December 31 of the calendar year.
This definition of retention is similar to the Health
Resources and Services Administration (HRSA) HIV/
123
1018
AIDS Bureau (HAB) metric for retention in place during
the bulk of our study period, and guidelines for clinical
practice that advised patients be seen approximately every
3–4 months for viral load monitoring [17, 18]. Because
HIV-infected patients in the JHHCC may receive HIV-
specific care outside of the HIV clinic but in the institution
(e.g., by their gynecologist), we counted any visit within
the Johns Hopkins Hospital medical campus (other than an
emergency room visit) as a clinical visit. We classified
patients as prescribed ART if they had at least one ART
prescription spanning C30 days during the calendar period.
ART prescriptions are those recorded in the medical record
(and due to the nature of the Johns Hopkins medical record
system sent to the pharmacy); we do not have information
on whether prescriptions were picked up. We classified
patients as virally suppressed if they had C1 HIV viral load
\400 copies/mL during the calendar year. Deaths were
obtained from clinic sources and regular matches against
the Social Security Death Index.
Definitions for retention in care, ART use and viral
suppression (Table 1) were chosen to be highly sensitive
for membership in each stage of the HIV care cascade.
More specific definitions for membership in each stage of
the HIV care cascade are possible. For example, we could
have defined viral suppression as having the most recent
HIV viral load measurement \400 copies/mL or all HIV
viral load measurements in the calendar year \400 copies/
mL. A threshold of\400 copies/mL was used rather than a
more stringent criterion such as \50 copies/mL since the
calendar time frame of our analysis substantially covered
years when \400 copies/mL was the clinical standard for
defining viral suppression. As a result of our highly sen-
sitive, but potentially less specific definitions, our results
should be interpreted as an upper bound for estimates of
retention in care, ART use and viral suppression. Due to
the nature of the data (clinical cohort) we are unable to
estimate the rate of entry to care after HIV diagnosis
(Fig. 1).
Table 1 HIV care continuum definitions for the current analyses
‘‘Active’’ patients Those with a clinic visit, CD4 cell count or viral load in July 1 of prior year to June 30 of present year
Retained patients Among active patients, those with C2 clinic visits, CD4 cell counts or viral loads (or any combination of those)
[90 days apart between January 1 and December 31 of present year
Proportion retained # Retained patients/# active patients
Patients using ART Among retained patients, those with C1 ART prescription for C30 days between January 1 and December 31 of
present year
Proportion using ART # Patients using ART/# active patients
Patients virally Among patients using ART, those with C1 HIV viral load \400 copies/mL between January 1 and December 31 of
suppressed present year
Proportion virally # Patients virally suppressed/# active patients
suppressed
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AIDS Behav (2017) 21:1016–1024
Analysis
We calculated crude proportions of patients retained, on
ART and virally suppressed as the proportion of active
patients who met the definition of retention, the propor-
tion of patients who met the definition of retention who
also met the definition for being on ART, and the pro-
portion of patients who met the definition for being on
ART who also met the definition for viral suppression,
respectively. That is, persons classified as being virally
suppressed were, by definition, a subset of those on ART.
Those on ART were, in turn, a subset of those retained,
and those retained were a subset of active patients. Per-
sons who died in a calendar year were included in the
numerator and denominator of any calculations if they
also met the definition the numerator or denominator prior
to death (i.e., persons were not excluded from estimates if
they died).
To quantitatively evaluate the association between IDU
and retention, ART use and viral suppression, and to
determine whether that association changed over time, we
fit inverse-probability weighted log-binomial regression
models for: (1) retention in care among active patients; (2)
ART use among those retained; and (3) viral suppression
among those on ART. Dependent variables in these models
were: IDU, indicator variables for calendar year (to allow
retention, ART use and viral suppression to vary over
time), and the product of IDU and calendar year indicator
variables (to be able to detect differences in the risk ratio
for retention, ART use and viral suppression associated
with IDU to vary over time). Because patients could con-
tribute multiple records to the analysis (one for each year in
which they were an active patient) we used generalized
estimating equations (GEE) with an exchangeable corre-
lation matrix to control for correlated observations. We
report the relative risk of retention, ART use and viral
suppression comparing PWID to non-IDU by year, stan-
dardized to the marginal distribution of: age, sex, race,
AIDS Behav (2017) 21:1016–1024
male-to-male sexual contact (MSM) acquisition risk,
heterosexual acquisition risk, and ART use, history of
AIDS diagnosis, and values of CD4 cell count and HIV
viral load at enrollment into the cohort. Standardization
was accomplished using inverse probability weights [19].
Weighted estimates control for differences in demographic
or baseline clinical characteristics among PWID and non-
IDU who enrolled, so that any disparities in continuum
outcomes are not due to these other patient characteristics.
We estimated the weights using predicted probabilities of
IDU acquisition risk from a logistic regression model for
IDU, with all of the standardization variables as predictors.
To improve model fit by allowing for a non-linear rela-
tionship between continuous variables and the probability
of reporting IDU acquisition risk, we modeled all contin-
uous variables using restricted quadratic splines with knots
at the 5th, 35th, 65th, and 95th percentiles [20]. We used
robust standard errors when calculating 95 % confidence
intervals for all estimates.
Secondary Analyses
A number of different definitions of retention in HIV
care have been employed in the literature [21, 22], and
HIV clinical care guidelines continue to change
(specifically, by increasing the acceptable interval
between visits for patients who are well-established on
ART and virally suppressed) [18, 23]. These changing
guidelines may affect the sensitivity of the current
HRSA definition of retention in care [24]. Therefore, we
examined the impact of several other retention defini-
tions. In addition to (1) our primary definition of
retention (C2 clinical visits [90 days apart), we also
considered the following definitions of retention: (2) C2
HIV-related laboratory measurements (CD4 cell count or
HIV viral load) [90 days apart; and (3) C2 routine,
general health-related laboratory measurements (he-
moglobin or sodium measurements) [90 days apart. The
second definition of retention is one primarily used by
HIV surveillance programs [25]. The third definition of
retention measures any engagement in medical care
within the Johns Hopkins system. We examined trends
in retention over time, stratified by IDU, according to of
these three definitions. We also compared subsequent
HIV care continuum outcomes (probability of being on
ART or virally suppressed), stratified by IDU, for per-
son-years meeting each of these three definitions (by
person-years we mean that patients contributed records
for each year in which they were active in the clinic,
each of which could be independently classified as
retained, on ART or virally suppressed). We conducted
all analyses in SAS 9.4 (SAS Institute Inc., Cary, NC).
1019
Results
Study Sample
There were 4602 persons enrolled in continuity care in the
JHHCC with at least one clinical visit, CD4 cell count or
HIV viral load between July 1, 2000 and June 30, 2012. Of
those, the majority were men, black, and heterosexual. The
median age at enrollment was 40 years [interquartile range
(IQR) 34, 47]. Most enrolled patients had some indication
of having been in care elsewhere previously: 52 % had a
history of antiretroviral use prior to enrollment and 27 %
had an AIDS diagnosis that preceded enrollment. Median
CD4 cell count at baseline was 282 (IQR: 105, 480) and
median log10 viral load was 4.3 (IQR 3.0, 5.0). Thirty-six
percent were classified as PWID based on HIV acquisition
risk (Table 2).
Each year, from 2001 to 2012, between 670 and 824
PWID and between 1145 and 1604 non-IDU were active
clinic patients (defined as having had a visit or an HIV
laboratory measurement in the last 6 months of the prior
year, or the first 6 months of the current year). The number
of active PWID declined very slightly over time, while the
number of active non-IDU increased over time.
Retention
The proportion of active clinic patients who had C2 clin-
ical visits in a given calendar year (retained) increased over
time for PWID, with the sharpest increase coming from
2007 (70.5 % retained) to 2008 (75.4 % retained)
(Table 3). The proportion of non-IDU retained was
approximately constant over time, and was higher than the
proportion of PWID in all years except 2012. The result of
these trends was that disparities in retention between PWID
and non-IDU disappeared over time. Indeed, after stan-
dardizing on baseline demographics and clinical status,
PWID had a statistically significantly lower probability of
being retained in care in all calendar years until 2010
(Table 4).
ART Use
The proportion of active PWID who were on ART
increased over time; increases were gradual and began
almost immediately from 2002–2003. In contrast, the
proportion of active non-IDU who were on ART was fairly
constant until 2007, increased until 2009, and remained
approximately constant again through the end of the study
period in 2012. Given PWID had a lower probability of
being retained than non-IDU, it is perhaps not surprising
that across all years, active PWID also had a lower
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1020 AIDS Behav (2017) 21:1016–1024

Table 2 Baseline characteristics of 4602 HIV-infected persons ever virally suppressed (Table 3). Among persons who were on
enrolled in the Johns Hopkins Clinical Cohort who had at least one ART, PWID and non-IDU had similar probabilities of
clinical visit, CD4 cell count or HIV viral load July 1, 2000–June 30,
being virally suppressed. For example, in 2012, the stan-
2012, stratified by self-report of injection drug use as their likely route
of HIV acquisition dardized relative risk of viral suppression comparing PWID
to non-IDU who were on ART was 0.98 (95 % CI 0.94,
N PWID Non-IDU Total
1659 2943 4602
1.03) (Table 4).

Male sexa 1104 (67 %) 1922 (65 %) 3026 (66 %) Supplemental Analyses: Defining Retention
b
Age 42 (37, 48) 39 (32, 46) 40 (34, 47)
Race We contrasted retention as defined by C2 clinical visits
Black 1365 (82 %) 2106 (72 %) 3471 (75 %) [90 days apart, with retention as defined by C2 HIV
White 273 (16 %) 702 (24 %) 975 (21 %) laboratory measurements [90 days apart and retention as
Other 21 (1 %) 135 (5 %) 156 (3 %) defined by C2 general laboratory measurements [90 days
HIV acquisition risk apart. Inference about patterns of retention over time for
MSM 142 (9 %) 1077 (37 %) 1219 (26 %) PWID and non-IDU were approximately the same
Heterosexual 756 (46 %) 1640 (56 %)s 2396 (52 %) regardless of the definition of retention used. Retention
History of any 865 (52 %) 1512 (51 %) 2377 (52 %) defined by clinical visits was generally lower than retention
antiretroviral use defined by HIV laboratory measurements. Among PWID,
AIDS 465 (28 %) 767 (26 %) 1232 (27 %) retention defined by HIV laboratory measurements was
CD4 cell count 285 (115, 486) 280 (98, 477) 282 (105, 480) generally lower than retention defined by general labora-
(cells/lL)b tory measurements. Among non-IDU, retention estimates
\50 232 (14 %) 494 (17 %) 726 (16 %) were generally equal or slightly higher when retention was
50–199 cells/lL 366 (22 %) 609 (21 %) 975 (21 %) defined by HIV laboratory measurements or general labo-
200–349 371 (22 %) 587 (20 %) 958 (21 %) ratory measurements (supplemental Table 2). The proba-
C350 cells/lL 636 (38 %) 1153 (39 %) 1789 (39 %) bility of ART use and viral suppression was highest in
Missing 54 100 154 person-years in which patients were classified as retained
Viral load (HIV 4.3 (3.0, 4.9) 4.3 (2.9, 5.0) 4.3 (3.0, 5.0) by both clinical visits and HIV laboratory measurements
RNA log10 (86.2 and 75.1 %, respectively), and lowest in person-years
copies/mL)b
in which patients were not classified as retained by either
Missing 194 286 480
definition (1.4 and 0.8 %, respectively), and was similar for
HIV human immunodeficiency virus, PWID persons who inject drugs, PWID and non-IDU (Table 5). Contrasting person-years in
IDU injection drug use, MSM men who have sex with men, ART
which patients were classified as retained by one measure
antiretroviral therapy, AIDS acquired immune deficiency syndrome
a but not both, ART use and viral suppression was generally
N (%) unless otherwise specified
b most prevalent when patients were retained by HIV labo-
Median (IQR)
ratory measurements and not clinical visits (75.6 and
60.2 %, respectively, compared to 71.5 and 43.5 %). Upon
probability of ART use (supplemental Table 1). Yet, knowing whether a patient was retained as defined by visits
among persons who were retained in care, standardizing on and as defined by HIV laboratory measurements, knowing
baseline demographics and clinical status, PWID and non- whether he or she was retained by general laboratory
IDU had similar probabilities of ART use [relative risk of measurements did not appreciably change estimates of the
ART use in 2012 was 0.94, 95 % confidence interval (CI) probability of ART use or viral suppression (supplemental
0.88, 1.01] (Table 4). Table 3).

Viral Suppression
Increases in viral suppression followed a pattern similar to
ART use, increasing gradually and consistently over the
12-year period covered by this study (Fig. 2). The pro-
portion of active non-IDU who were virally suppressed was
consistently higher than the proportion of PWID who were
suppressed, but the difference in proportion suppressed
decreased over time. By 2012, 69.1 % of active PWID
were virally suppressed while 71.0 % of non-IDU were
Discussion
We used the HIV care continuum framework to measure
engagement in HIV clinical care among PWID and non-
IDU over time in a single, large, urban HIV clinic. Prob-
ability of retention in care, ART use and viral suppression
all increased over time. In nearly all calendar years, the
probability of retention in care, ART use or viral sup-
pression was lower among PWID compared to non-IDU.

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AIDS Behav (2017) 21:1016–1024 1021

Table 3 Crude number and proportion of HIV-infected persons in the Johns Hopkins HIV Clinical Cohort retained, on ART, and virally
suppressed, stratified by calendar year and history of injection drug use
PWID Non-IDU
b c
Active Retained On ART Virally Active Retainedb On ARTc Virally
patientsa N (%) N (%) suppressedd patientsa N (%) N (%) suppressedd
N N (%) N N (%)

2001 756 517 (68.4 %) 344 (45.5 %) 212 (28.0 %) 1145 909 (79.4 %) 714 (62.4 %) 478 (41.7 %)
2002 822 553 (67.3 %) 361 (43.9 %) 248 (30.2 %) 1253 1000 (79.8 %) 748 (59.7 %) 526 (42.0 %)
2003 824 574 (69.7 %) 393 (47.7 %) 271 (32.9 %) 1311 1061 (80.9 %) 782 (59.6 %) 559 (42.6 %)
2004 794 561 (70.7 %) 398 (50.1 %) 282 (35.5 %) 1344 1087 (80.9 %) 836 (62.2 %) 652 (48.5 %)
2005 754 509 (67.5 %) 381 (50.5 %) 308 (40.8 %) 1345 1097 (81.6 %) 859 (63.9 %) 683 (50.8 %)
2006 702 498 (70.9 %) 386 (55.0 %) 320 (45.6 %) 1347 1082 (80.3 %) 870 (64.6 %) 740 (54.9 %)
2007 709 500 (70.5 %) 410 (57.8 %) 347 (48.9 %) 1412 1120 (79.3 %) 965 (68.3 %) 829 (58.7 %)
2008 703 530 (75.4 %) 450 (64.0 %) 394 (56.0 %) 1422 1183 (83.2 %) 1057 (74.3 %) 953 (67.0 %)
2009 708 566 (79.9 %) 482 (68.1 %) 439 (62.0 %) 1480 1257 (84.9 %) 1131 (76.4 %) 1049 (70.9 %)
2010 720 560 (77.8 %) 499 (69.3 %) 456 (63.3 %) 1547 1268 (82.0 %) 1157 (74.8 %) 1085 (70.1 %)
2011 696 547 (78.6 %) 493 (70.8 %) 453 (65.1 %) 1584 1308 (82.6 %) 1232 (77.8 %) 1126 (71.1 %)
2012 670 551 (82.2 %) 511 (76.3 %) 463 (69.1 %) 1604 1297 (80.9 %) 1237 (77.1 %) 1139 (71.0 %)
PWID persons who inject drugs, IDU injection drug use, self-reported transmission risk
a
‘‘Active’’ patient defined as having had C1 clinical visit, CD4 cell count, or HIV viral load measurement between July 1 of the prior year and
June 30 of the calendar year of interest
b
Retained in care defined as attending C2 clinical visits in the Johns Hopkins Medical system[90 days apart between January 1 and December
31 of the calendar year, conditional on being an active patient
c
On ART defined as having C1 antiretroviral prescription for C30 days, conditional on being retained in care
d
Viral suppression defined as having CHIV viral load measurement \400 copies/mL, conditional on being on ART

However, disparities between PWID and non-IDU were no
longer statistically significant after 2010, and were nearly
mitigated by 2012. When we conditioned on engagement in
the prior continuum stage, after around 2003–2004, among
people retained in care, PWID and non-IDU had similar
probabilities of having had a prescription for ART and
among people on ART, PWID and non-IDU had approxi-
mately the same probability of having at least one unde-
tectable viral load measurement.
Prior studies have reported on poorer retention in care,
lower probability of ART use, and lower probability of
viral suppression among PWID compared to non-IDU
[6, 13–15], but we believe this study to be one of the first
to consider all three outcomes together, over time. By
including calendar time in our analysis, we have been able
to document improvements in retention among PWID such
that the probability of retention in recent years was sta-
tistically indistinguishable comparing PWID and non-IDU.
There are multiple interventions that have been shown to
increase engagement in care [26–28] and the Johns Hop-
kins HIV Clinic has put a priority on retention. By con-
sidering all three outcomes together, we were able to
determine that the lower probability of viral suppression
seen among PWID may primarily be a function of ART
use.
Another strength of our analysis was the consideration
of several different definitions of retention. Although
HRSA recommends measuring retention using visit atten-
dance, public health surveillance data is forced to rely on
laboratory-based measures of retention [29]. We did not
consider the other main retention measure: missed clinical
visits. The definitions of retention are not perfectly corre-
lated, as seen in our study and as reported previously
[21, 22]. Our results indicate that considering both reten-
tion measures provides additional information about
patients’ level of engagement in care, beyond the infor-
mation provided in a single measure alone.
As mentioned in the methods section, the definitions of
retention, ART use and viral suppression were highly
sensitive, but not particularly specific. This may have
implications for our finding that PWID who were on ART
were not less likely to be virally suppressed compared to
non-IDU. In a previous examination comparing PWID and
non-IDU in the JHHCC, it was found that PWID spent
more time after enrollment on ART but not virally sup-
pressed [30]. In this study, PWID who had at least one viral
load measure \400 copies/mL (and classified as virally
suppressed) may have been more likely to have other viral
load measures during the calendar year C400 copies/mL
than non-IDU. If we had, instead, used a stricter definition

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Table 4 Risk ratio (95 % confidence interval) for association between IDU and membership within each stage of the HIV care continuum,
conditional on being an active patient (for retained) or membership in preceding stage (for on ART and virally suppressed), by calendar year
Crude Standardizeda
Retainedb On ARTc Virally suppressedd Retainedb On ARTc Virally suppressedd

2001 0.85 (0.80, 0.90) 0.83 (0.78, 0.90) 0.89 (0.81, 0.99) 0.84 (0.77, 0.92) 0.88 (0.79, 0.97) 0.94 (0.81, 1.09)
2002 0.83 (0.78, 0.87) 0.86 (0.81, 0.93) 0.97 (0.90, 1.06) 0.86 (0.79, 0.93) 0.88 (0.78, 0.98) 1.05 (0.94, 1.18)
2003 0.84 (0.80, 0.89) 0.90 (0.84, 0.96) 0.95 (0.88, 1.03) 0.86 (0.79, 0.93) 0.87 (0.77,0.98) 0.90 (0.76, 1.05)
2004 0.85 (0.81, 0.90) 0.91 (0.85, 0.96) 0.90 (0.84, 0.97) 0.91 (0.85, 0.98) 0.90 (0.81, 1.00) 0.85 (0.73, 0.98)
2005 0.80 (0.76, 0.85) 0.93 (0.87, 0.98) 1.01 (0.95, 1.07) 0.82 (0.75, 0.89) 0.89 (0.80, 0.99) 1.01 (0.91, 1.12)
2006 0.86 (0.81, 0.91) 0.95 (0.90, 1.00) 0.97 (0.92, 1.02) 0.86 (0.78, 0.94) 0.98 (0.89, 1.08) 0.90 (0.78, 1.04)
2007 0.86 (0.81, 0.91) 0.94 (0.89, 0.98) 0.98 (0.93, 1.03) 0.82 (0.74, 0.92) 0.98 (0.92,1.05) 1.02 (0.96, 1.09)
2008 0.89 (0.84, 0.93) 0.94 (0.91, 0.98) 0.96 (0.92, 1.00) 0.89 (0.82, 0.97) 0.96 (0.90, 1.02) 0.96 (0.90, 1.03)
2009 0.93 (0.89, 0.98) 0.93 (0.90, 0.97) 0.97 (0.94, 1.00) 0.93 (0.87, 0.99) 0.95 (0.89, 1.02) 0.99 (0.95, 1.03)
2010 0.94 (0.89, 0.99) 0.96 (0.93, 0.99) 0.96 (0.93, 0.99) 0.95 (0.88,1.03) 0.95 (0.87, 1.03) 0.99 (0.96, 1.02)
2011 0.94 (0.89, 0.98) 0.95 (0.92, 0.98) 0.99 (0.95, 1.02) 0.93 (0.85, 1.03) 0.94 (0.89, 1.00) 0.99 (0.95, 1.03)
2012 1.01 (0.96, 1.06) 0.96 (0.93, 0.98) 0.97 (0.93, 1.00) 0.99 (0.92, 1.07) 0.94 (0.88, 1.01) 0.98 (0.94, 1.03)
HIV human immunodeficiency virus, PWID persons who inject drugs, IDU injection drug use, MSM men who have sex with men, ART
antiretroviral therapy, AIDS acquired immune deficiency syndrome
a
Standardized by sex, age, race, MSM and heterosexual transmission risk, and history of ART, AIDS, CD4 cell count and HIV viral load at
enrollment
b
Retained in care defined as attending C2 clinical visits in the Johns Hopkins Medical system[90 days apart between January 1 and December
31 of the calendar year, conditional on being an active patient
c
On ART defined as having C1 antiretroviral prescription for C30 days, conditional on being retained in care
d
Viral suppression defined as having CHIV viral load measurement \400 copies/mL, conditional on being on ART

Fig. 2 Proportion of HIV-

infected persons in the Johns
Hopkins HIV Clinical Cohort
expected to be in care in each
calendar year who were
retained, on ART and virally
suppressed, stratified by history
of injection drug use,
2001–2012. ART antiretroviral
therapy, IDU injection drug use,
PWID persons who inject drug

of viral suppression, such as ‘‘all viral load measurements
during the calendar year \400 copies/mL,’’ we may have
inappropriately classified persons as not suppressed if they
were unsuppressed at the beginning of the year, but initi-
ated ART during the calendar year and had all subsequent
viral load measurements \400 copies/mL. Reconciling
these issues requires shifting estimation of the HIV care
continuum from purely cross-sectional to be more longi-
tudinal [30].
While our definitions of retention, ART use and viral
suppression were highly sensitive, we did exclude patients
from being classified as on ART if they were not retained or

123
AIDS Behav (2017) 21:1016–1024 1023

Table 5 Comparison of
Retained by visits Yes No
person-years (PY) according to
Retained by HIV labs
their classification as ‘‘retained’’ Yes No Yes No
based on three different
definitions of retention in care, PWID
stratified by IDU Person-years 4374 541 1498 2445
PY (%) on ART 3643 (83.3 %) 343 (63.4 %) 1096 (73.2 %) 26 (1.1 %)
PY (%) virally suppressed 3120 (71.3 %) 196 (36.2 %) 866 (57.8 %) 11 (0.4 %)
Non-IDU
Person-years 10,222 961 2416 3195
PY (%) on ART 8943 (87.5 %) 731 (76.1 %) 1863 (77.1 %) 51 (1.6 %)
PY (%) virally suppressed 7839 (76.7 %) 457 (47.6 %) 1489 (61.6 %) 34 (1.1 %)
IDU injection drug use, self-reported HIV transmission risk, PWID persons who inject drugs, PY person-
year

from being classified as virally suppressed if they were not
on ART (supplemental Table 4). Including these people as
on ART or virally suppressed, respectively, would neces-
sarily increase our estimates of the proportion of patients
meeting those definitions, but not the observed patterns.
Furthermore, patients on ART but not retained are less likely
to be stable on ART throughout the year, and patients who
are virally suppressed but not on ART are less likely to be
stably virally suppressed throughout the year. Thus esti-
mates of ART use and viral suppression that included these
patients are likely to be misleadingly optimistic.
A limitation of our analysis is that IDU was measured
only as self-reported history of IDU at enrollment into
HIV clinical care. There is the possibility that due to
social desirability bias, new patients would under-report
history of IDU. However, physicians in the Johns Hopkins
HIV clinic are non-judgmental in their interactions with
patients while ascertaining HIV acquisition risk and the
prevalence of reported IDU was high in this cohort. As
such, we believe under-reporting of IDU in this clinical
cohort to be similar to or less than other clinical cohorts.
History of IDU is not equivalent to ongoing drug use (and
non-IDU can use illicit drugs) so our results do not cor-
respond to the association between current drug use and
retention, ART use or viral suppression. Further investi-
gations into current illicit drug use could provide insights
into the observed association between history of IDU and
ART use. However, for measuring and monitoring dis-
parities in progression through the HIV care continuum,
history of IDU is measured consistently across nearly all
HIV cohorts, which allows for comparability between
studies. Under-ascertainment of IDU would likely bias
our estimates of disparities comparing PWID and non-
IDU toward the null (since PWID incorrectly classified as
non-IDU would make the non-IDU group look more like
the PWID).
In conclusion, we have documented improvements in
HIV clinical engagement for PWID and the
diminishment of disparities in retention, ART use and
viral suppression between PWID and non-IDU. Reduc-
tions in disparities appear to be primarily driven by
increases in retention and ART use (rather than viral
suppression while on ART). Retention is not a simple
concept to measure, and understanding the many dif-
ferent ways that patients engage with the healthcare
system may help identify barriers to care and opportu-
nities for increasing retention and subsequent engage-
ment for both PWID and non-IDU.
Funding This work was supported by NIH Grants U01 DA036935
and P30 AI094189.
Compliance with Ethical Standards
Conflict of Interest CRL has received a speaker honorarium from
Gilead Sciences, Inc. for work unrelated to this manuscript. No other
authors have conflicts of interest to report.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed Consent Informed consent was obtained from all indi-
viduals included in this study.
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